PATHOLOGIC OB: Page | 1

DULIG, Argent Aebi DP

ANTEPARTUM HEMORRHAGE

PLACENTAL ABRUPTION
premature separation of the normally implanted placenta

Etiology
RISK FACTORS RELATIVE RISK
Increased age and parity 1.31.5
Preeclampsia 2.14.0
Chronic hypertension 1.83.0
Preterm ruptured membranes 2.44.9
Preterm ruptured membranes 2.1
Hydramnios 2.0
Cigarette smoking 1.41.9
Thrombophilias 37
Cocaine use NA
Prior abruption 1025
Uterine leiomyoma NA

Pathology
Initiated by hemorrhage into the decidua basalis.
In its earliest stages consists of the development of a decidual hematoma that leads to
separation, compression, and the ultimate destruction of the placenta adjacent to it
In some instances, a decidual spiral artery ruptures to cause a retroplacental hematoma,
which as it expands disrupts more vessels to separate more placenta

CONCEALED HEMORRHAGE
Retained or concealed hemorrhage is likely when:
There is an effusion of blood behind the placenta but its margins still remain adherent.
The placenta is completely separated yet the membranes retain their attachment to the
uterine wall.
Blood gains access to the amnionic cavity after breaking through the membranes.
The fetal head is so closely applied to the lower uterine segment that the blood cannot
make its way past it.

Signs and Symptoms Determined Prospectively in 59 Women with Abruptio Placentae
Sign or Symptom Frequency (%)
Uterine tenderness or back pain 78
66
Fetal distress 60
Preterm labor 22
High-frequency contractions 17
Hypertonus 17
Dead fetus 15

Differential Diagnosis
Vaginal bleeding complicating a viable pregnancy, it often becomes necessary to rule
out placenta previa and other causes of bleeding by clinical inspection and ultrasound
evaluation.
Painful uterine bleeding means placental abruption, whereas painless uterine bleeding
is indicative of placenta previa.
Labor accompanying placenta previa may cause pain suggestive of placental abruption.
Abruption may mimic normal labor, or it may cause no pain at all. The latter is more
likely with a posteriorly implanted placenta

CONSUMPTIVE COAGULOPATHY
One of the most common causes of clinically significant consumptive coagulopathy in
obstetrics is placental abruption
Overt hypofibrinogenemia (less than 150 mg/dL of plasma) along with elevated levels of
fibrinogenfibrin degradation products, D-dimers, and variable decreases in other
coagulation factors are found in about 30 percent of women with placental abruption
severe enough to kill the fetus
activation of plasminogen to plasmin, which lyses fibrin microemboli, thereby
maintaining patency of the microcirculation

RENAL FAILURE
seen in severe forms of placental abruption, includes those in which treatment of
hypovolemia is delayed or incomplete
Seriously impaired renal perfusion is the consequence of massive hemorrhage.
vigorous treatment of hemorrhage with blood and crystalloid solution often prevents
clinically significant renal dysfunction


COUVELAIRE UTERUS
(UTEROPLACENTAL APOPLEXY)
Widespread extravasation of blood into the uterine musculature and beneath the
uterine serosa
occasionally seen beneath the tubal serosa, in the connective tissue of the broad
ligaments, and in the substance of the ovaries, as well as free in the peritoneal cavity
seldom interfere with uterine contractions sufficiently to produce severe postpartum
hemorrhage
Not an indication for hysterectomy.





PATHOLOGIC OB: Page | 2
DULIG, Argent Aebi DP
Management for Abruptio placenta



PLACENTA PREVIA
In placenta previa, the placenta is located over or very near the internal os. Four degrees of this
abnormality have been recognized.
Total placenta previa
The internal cervical os is covered completely by placenta
Partial placenta previa
The internal os is partially covered by placenta
Marginal placenta previa
The edge of the placenta is at the margin of the internal os.
Low-lying placenta
The placenta is implanted in the lower uterine segment such that the
placenta edge actually does not reach the internal os but is in close proximity
to it.
Vasa previa
The fetal vessels course through membranes and present at the cervical os




Factors associated with Placenta Previa:
Advancing maternal age
At the extremes, it is 1 in 1500 for women 19 years of age or younger, and it is
1 in 100 for women older than 35 years of age.

Multiparity
40 percent higher in multifetal gestations compared with that of singletons.
Previous pregnancies permanenetly damage the endometriu underlying the
placental site making suitable for the placenta in subsequent pregnancies
Prior cesarean delivery
A prior uterine incision with a previa increases the incidence of cesarean
hysterectomy.
Defective vascularization of the deciduas as a result of inflammatory or
atrophic changes
Smoking
Relative risk of placenta previa to be increased twofold
Carbon monoxide hypoxemia caused compensatory placental hypertrophy

Diagnosis
Placenta previa or abruption should always be suspected in women with uterine
bleeding during the latter half of pregnancy.
seldom be established firmly by clinical examination unless a finger is passed through
the cervix and the placenta is palpated. Such examination of the cervix is never
permissible unless the woman is in an operating room with all the preparations for
immediate cesarean delivery, because even the gentlest examination of this sort can
cause torrential hemorrhage
safest method of placental localization is provided by transabdominal sonography
Magnetic Resonance Imaging

PLACENTAL MIGRATION
mechanism of apparent placental movement.
The term migration is clearly a misnomer, however, because invasion of chorionic villi
into the decidua on either side of the cervical os persists.
This difficulty is coupled with differential growth of lower and upper myometrial
segments as pregnancy progresses.
Thus, those placentas that "migrate" most likely never had actual circumferential villus
invasion that reached the internal cervical os in the first place.





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DULIG, Argent Aebi DP
Management
Women with a placenta previa may be considered as follows:
Those in whom the fetus is preterm and there is no indication for delivery.
Target date: 37 weeks
Hospitalization, replace blood loss, keep crossmatched blood available, bed rest under
close observation
May go home provided that patient lives within 20-30 minutes from the hospital
Those in whom the fetus is reasonably mature. Delivery by Cesarean section
Those in labor.
General rule: method of delivery of choice in patients with degree of placenta previa is
Ceasarean section EXCEPT in cases of marginal or low lying placenta implanted
anteriorly with advanced cervical dilatation and head is engaged
Those in whom hemorrhage is so severe as to mandate delivery despite fetal
immaturity.


ABRUPTIO PLACENTA PLACENTA PREVIA
History Frequent association of pre-
eclampsia or hypetension from
any cause
A single attack of vaginal
bleeding which usually continues
until delivery
Abdominal pain
No association with pre-eclampsia
Repeated warning hemorrhages
often occurring over a period of
weeks
No abdominal pain
Abdominal
examination
Local uterine tenderness,
hypertonic uterus in a concealed
abruption
Patients usually in labor
Presenting part not engaged
Fetal parts maybe difficult to
palpate
FHT often absent
Normal uterine tone and usually
no tenderness
Patient rarely in labor
Presenting part above brim,
malpresentation frequently found
Fetal parts usually palpable
FHT present
Ancillary Aids Placenta demonstrated in the
upper uterine segment
Placenta demonstrated in the
lower uterine segment
Vaginal examination NO placenta within 5 cm of the
cervical os
Placenta implanted in the Lower
uterine segment
Management No place in expectant
management
< 36 week, bleeding stopped,
expectant management is
indicated